Basic Information
Provider Information | |||||||||
NPI: | 1184166027 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BURRELL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BURRELL BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1300 E BRADFORD PKWY | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658044264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177615000 | ||||||||
FaxNumber: | 4177615011 | ||||||||
Practice Location | |||||||||
Address1: | 1300 E BRADFORD PKWY | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658044264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177615000 | ||||||||
FaxNumber: | 4177615011 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2016 | ||||||||
LastUpdateDate: | 01/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARTER | ||||||||
AuthorizedOfficialFirstName: | AMANDA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4177615126 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 880038895 | 05 | MO |   | MEDICAID |